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Diagnosis and Treatment of RSI

Diagnosis

In our first RSI booklet in 1988, we highlighted the problem of getting a correct diagnosis for RSI. Unfortunately, in 1996, diagnosis of RSI is still difficult especially for the diffuse forms where the pathology of the injury is still not fully understood. And of course without a proper diagnosis it is difficult for sufferers to obtain the most appropriate treatment. Even localised conditions which are better understood may exist side by side with diffuse RSI so that treatment directed at the localised condition alone will be unsuccessful in dealing with the RSI as a whole.

There is still a great deal of controversy about RSI and its pathology and the average GP is ill informed about the general nature of RSI let alone any current clinical theories about it. At the time of writing two theories about diffuse RSI are gaining prominence and are described briefly by the late Stephen Pheasant, consulting ergonomist and acknowledged authority on RSI, in Physiotherapy and Occupational Health (Ed. Richardson and Eastlake).

The first of the theories, and that favoured by Pheasant himself, considers diffuse RSI to be a painful condition of the muscles, due partly to an overuse injury and partly to a sensitisation of the nerves. The condition may also have a psychological component especially in chronic cases. This theory is supported by various sets of experimental evidence, for example that of Dennett and Fry in Australia which was based on evidence from biopsy studies. They identified structural differences in the muscle tissue of diffuse RSI sufferers and non-sufferers which they believed could not be accounted for by known psychological mechanisms. This sort of evidence is important not only for understanding the pathology of diffuse RSI but also because it demonstrates that RSI does have an organic pathology and is therefore not all in the mind as some people have tried to suggest.

The second theory is that diffuse RSI is principally the result of the irritation of nerve tissues because of changes induced by what is called adverse mechanical (or neural) tension or altered neurodynamics. It derives from work done in Australia , where there was a widespread incidence of RSI in the Eighties, and has been described by Quintner and Elvey amongst others. In the UK this theory has been adopted by Jeffrey Boyling, physiotherapist and ergonomist and advisor on clinical matters to the Chartered Society of Physiotherapy, who has also emphasised the role of muscle imbalance. The reason that this theory is considered so important is that increasingly clinical experience is indicating that methods of treating diffuse RSI based on this theory are proving to be more effective than other forms of treatment.

Clearly more research is needed into diffuse RSI. However, it seems likely that elements of both theories will prove to be involved rather than a single causation being identified. What is clear, according to Pheasant, is that the clinical manifestations of diffuse RSI are sufficiently consistent as to indicate that there is a specific clinical condition known as RSI in addition to the localised conditions such as tenosynovitis.

However, many RSI sufferers have been met by ignorance, indifference or denial on the part of the medical profession. A survey of RSI sufferers’ experience of doctors carried out by Hilary Arksey for the TUC found that only half the respondents said their GP believed in RSI. Most GPs, the first point of contact for most sufferers, lack training in occupational health and are unable to diagnose RSI conditions precisely. Many, under severe time pressure themselves, prescribe painkillers to relieve the symptoms but do not refer the patient on to a specialist for a correct diagnosis and treatment. Some GPs refuse to give a diagnosis because they think they will be drawn into protracted paperwork in a compensation claim. Many are reluctant to state that a condition is work related. A few have even been known to refer dismissively to their patient’s condition as compensationitis. Other GPs equate all RSI with tenosynovitis and diagnose accordingly, albeit with good intentions. The result is that the sufferer may receive the wrong treatment and may also get involved in an ill-founded and stressful claim for benefit since tenosynovitis is a prescribed industrial disease whereas most RSI conditions are not.

Even when a GP does refer the sufferer to a specialist, hospital waiting lists are so long that it can be six months or more before they get an appointment, by which time they may be in chronic pain, particularly if they have been continuing to work in the meantime. Moreover, they may have to be passed around several specialists before a final diagnosis is made and treatment begins. Those specialists most involved in treating RSI are physiotherapists, rheumatologists, hand surgeons and psychotherapists. Again, not all are sympathetic. One London woman, in great pain and finally having been referred to a consultant, was met with an extremely hostile response, constant assertions that she wouldn’t qualify for compensation, much talk about her pain being psychological and almost no discussion about her clinical condition. Her first reaction on leaving the hospital was whether she should phone the Samaritans. Fortunately she had a local RSI support group to turn to.

The worst thing a GP can do for an RSI sufferer is to prescribe painkillers and send them back to work. The best thing they can do given the present state of knowledge is to refer them to a specialist even if this does mean a long wait. They should also urge the sufferer to contact their union if they have not already done so.

It is important that a written note is made by the GP or hospital of any physical signs, eg swelling. This could be crucial evidence in later proceedings.

Treatment

Once the RSI sufferer has been given a diagnosis they need to be given the appropriate treatment. Unfortunately this is another area where there is disagreement amongst the medical profession. Sufferers need to be aware of all the options open to them so that they remain in control and can make informed decisions about whether to accept a particular treatment or seek a second opinion. The following is a list of some of the treatments available. It should be emphasised that the London Hazards Centre does not have any medically qualified staff and is not making any clinical recommendations, only setting out some of the options. The important thing is that treatment should begin as early as possible. If the condition reaches the chronic stage recovery may take years and it may be too late for complete recovery to be effected.

Rest

Rest is essential. The question is: how much rest is needed and what form should it take? Doctors used to prescribe a prolonged period of complete rest and some still believe that this is the best treatment. However too much rest may lead to muscle weakening and may not be the best treatment where the problem arose because the person maintained a static posture. To return straightaway to the same job which caused the RSI and at the same work pace after a long rest is a recipe for a rapid recurrence of the problem.

It is generally agreed that the important thing is to stop immediately the activity that was causing the problem and any similar activities. A short period of complete rest may be helpful particularly if inflammation is present. Painkillers may be taken during this period to help reduce the inflammation. After that most medical practitioners now recommend gentle exercise to help keep the limb mobile and avoid weakening of the muscle. In an RSI Association survey sufferers reported that a combination of rest, relaxation and gentle exercise was generally helpful.

Immobilisation

A common way of resting the limb is to immobilise it in a splint. This may protect the injured part but it could lead to the problem occurring in a different part of the limb. The compression of the splint could affect the functioning of the blood supply and nerve tissue. Also prolonged immobilisation can lead to wastage of the muscle and weakening of the limb. If splints are used they should not be worn for more than a few hours at a time. Some sufferers may be tempted to use splints unnecessarily because they at least give visible evidence that they have an injury.

Physiotherapy

Physiotherapy appears to be found by sufferers to offer the best treatment although this, too, is a controversial area. There are many different approaches that can be used and some of the standard forms of physiotherapy are completely inappropriate for the treatment of RSI, especially diffuse cases, and may make the condition worse. This may account for the fact that in surveys carried out for the RSI Association and the TUC a substantial percentage of respondents said that physiotherapy had not helped them.

Chartered physiotherapists are trained in treating muscle, joint and ligament complaints. It is important that the treatment is administered by a physiotherapist who is experienced in treating overuse injuries. Wherever possible a physiotherapist who has received specialist post-graduate training in neurodynamics and how to identify and treat problems of adverse neural tension should be sought since available evidence indicates that this treatment is giving the best results. However there are still very few NHS practitioners who have had training in these new techniques. Those who have been trained are mainly in private practice.

The aim of any treatment is to restore normal function to those tissues which are not normal. The sufferer should understand what tissues have been affected, what they should or should not do and when to exercise or rest. The treatment programme should be tailored to the individual and may involve a range of treatments including exercises and/or stretching of muscles and nerves, joint mobilisation, electrotherapy and ultrasound. Hydrotherapy or the use of ice packs may also be recommended to relieve pain and to complement the treatment. There are long waiting lists for most NHS physiotherapy services and the number that can offer the new specialist techniques is extremely limited.

Holistic approaches

RSI sufferers who are in chronic pain may benefit from the holistic treatments offered by pain management clinics such as the INPUT unit at St. Thomas’ Hospital in London. These recognise the role of the sympathetic nervous system and of psychological factors in chronic cases, which mean that RSI sufferers may experience pain long after the RSI symptoms have gone and can become trapped in a downward spiral of pain, depression and despair. Treatment is therefore based on a mixture of physiotherapy and cognitive behaviour therapy and is aimed at teaching people to understand pain, enabling them to manage their own pain, helping them to recover through a programme of graduated exercise and relaxation techniques, and providing them with an understanding of good ergonomic principles. Counselling may also be provided. Regrettably there are only two such clinics in the country at the time of writing and waiting lists for referral are several months long.

Drugs or surgery

Medical treatment in the form of pain-relieving and anti-inflammatory drugs or steroid and non-steroidal injections may be offered but these are of limited value and may be positively dangerous if they are used to mask pain and enable the person to return to the work activity causing the injury.

Surgery may be suggested, usually in cases of carpal tunnel syndrome to relieve pressure on the nerve, but again this is of doubtful value since it does not always provide the relief anticipated and may even make the condition worse. Moreover, it is of little use if the sufferer returns to the same bad working conditions.

Complementary therapies

There are many forms of complementary therapy available although they are rarely provided under the NHS and can be very expensive. None are specifically designed to treat RSI but the holistic approach they offer may be of benefit in relieving pain or stress, aiding relaxation and helping with good posture. They may be used where conventional methods have failed or to complement conventional treatment. However, in the latter case it is usually advisable to inform your medical practitioner to ensure that the treatments are compatible. It is important to check that the therapist is qualified and competent. It is also important to cease the treatment if it is not helping. The sorts of therapy that some RSI sufferers have used and found beneficial include acupuncture, aromatherapy, reflexology, Alexander Technique, yoga and relaxation techniques. However, the effectiveness of these therapies has not been assessed in any systematic way.

Prevention rather than cure

It is evident from the above that both diagnosis of RSI, particularly its diffuse forms, and treatment of RSI remain contentious issues and more research is needed before its pathology is fully understood. To make matters worse, underfunding of the NHS, especially the non-glamorous disciplines such as physiotherapy, coupled with inadequate occupational health training and provision means that what treatment is available to RSI sufferers is spread very thinly and is hugely oversubscribed. Sufferers may have to wait so long for referral that their condition is well progressed before treatment becomes available.

By contrast, however, the risk factors for RSI are well known and have been well established for many years. Clearly the solution to RSI is to prevent it from occurring in the first place by the application of sound ergonomic principles to work and workplace design. Certainly any treatment of existing sufferers must include remedial measures in the workplace. Treatment will have been of only partial benefit if the risk factors likely to provoke a recurrence of the condition are allowed to remain.

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